=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386866747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAVES FAMILY CARE HOME 1
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2896 STONEY CREEK SCHOOL RD
-----------------------------------------------------
City | REIDSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27320-0410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-421-0016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2872 STONEY CREEK SCHOOL RD
-----------------------------------------------------
City | REIDSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27320-0410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. ROBIN F GRAVES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-421-0016
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | FCL-017-008
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------